AHCCCS Pharmacy and Therapeutics Committee Recommendations 16 October

AHCCCS Pharmacy and Therapeutics Committee Recommendations 16 October 2019

Committee Recommendations PDL Recommendation Key: • Products currently preferred and remaining preferred are listed in Black • Products currently new, not previously reviewed or non-preferred and recommended to be preferred are listed in Blue • Products currently new, not previously reviewed or preferred and recommended to be non-preferred are listed in Red • Products currently included on the AHCCCS approved drug list are noted with an asterisk (*) • Classes where grandfathering is recommended will have a notation on the preferred recommendations page

P&T Public Class Vote: Antifungals, Oral Reaching across Arizona to provide comprehensive quality health care for those in need 3

Antifungals, Oral Current PDL (preferred products): • CLOTRIMAZOLE (MUCOUS MEM) • FLUCONAZOLE SUSPENSION (ORAL)* • FLUCONAZOLE TABLET (ORAL)* • GRISEOFULVIN SUSPENSION (ORAL)* • GRISEOFULVIN TABLETS (ORAL)* • NYSTATIN SUSPENSION (ORAL)* • NYSTATIN TABLET (ORAL)* • TERBINAFINE (ORAL)* Reaching across Arizona to provide comprehensive quality health care for those in need 4

P&T Public Class Vote: Antifungals, Topical Reaching across Arizona to provide comprehensive quality health care for those in need 5

Antifungals, Topical Current PDL (preferred products): • MICONAZOLE CREAM OTC (TOPICAL)* • CICLOPIROX CREAM (TOPICAL) • MICONAZOLE OINT OTC (TOPICAL)* • CICLOPIROX SOLUTION (TOPICAL) • MICONAZOLE POWDER OTC (TOPICAL)* • CICLOPIROX SUSPENSION (TOPICAL) • MICONAZOLE SPRAY OTC (TOPICAL) • CLOTRIMAZOLE-BETAMETHASONE CREAM (TOPICAL)* • NYSTATIN CREAM (TOPICAL)* • CLOTRIMAZOLE CREAM OTC (TOPICAL)* • NYSTATIN OINT (TOPICAL)* • CLOTRIMAZOLE CREAM RX (TOPICAL)* • NYSTATIN POWDER (TOPICAL)* • CLOTRIMAZOLE SOLUTION OTC (TOPICAL)* • TERBINAFINE CREAM OTC (TOPICAL) • CLOTRIMAZOLE SOLUTION RX (TOPICAL)* • TOLNAFTATE CREAM OTC (TOPICAL) • KETOCONAZOLE CREAM (TOPICAL)* TOLNAFTATE POWDER OTC (TOPICAL) KETOCONAZOLE SHAMPOO (TOPICAL)* • • • LOTRIMIN ULTRA OTC (TOPICAL) • TOLNAFTATE SPRAY OTC (TOPICAL) • TOLNAFTATE AERO POWDER OTC (TOPICAL) 6

P&T Public Class Vote: Antimigraine Agents, Triptans Reaching across Arizona to provide comprehensive quality health care for those in need 7

Antimigraine Agents, Triptans PDL Recommendations (preferred products): • SUMATRIPTAN (NASAL) • SUMATRIPTAN (ORAL) • IMITREX (NASAL) • SUMATRIPTAN VIAL (SUBCUTANE. ) • NARATRIPTAN (ORAL) • ZOLMITRIPTAN ODT (AG) (ORAL) • RIZATRIPTAN ODT (ORAL) • ZOLMITRIPTAN ODT (ORAL) • RIZATRIPTAN TABLET (ORAL) • ZOLMITRIPTAN TABLET (AG) (ORAL) • SUMATRIPTAN KIT (SUBCUTANE. ) • ZOLMITRIPTAN TABLET (ORAL) • SUMATRIPTAN KIT (SUN) (SUBCUTANE. ) • ZOMIG (NASAL) GRANDPARENTING - NO Reaching across Arizona to provide comprehensive quality health care for those in need 8

P&T Public Class Vote: Beta Blockers Reaching across Arizona to provide comprehensive quality health care for those in need 9

Beta Blockers PDL Recommendations (preferred products): • ATENOLOL (ORAL)* • ATENOLOL / CHLORTHALIDONE (ORAL)* • BISOPROLOL HCTZ (ORAL) • BISOPROLOL (ORAL) • CARVEDILOL (ORAL)* • LABETALOL (ORAL)* • METOPROLOL / HCTZ (ORAL) • METOPROLOL (ORAL)* • METOPROLOL XL (ORAL)* • NADOLOL / BENDROFLUMETHIAZIDE (ORAL) • NADOLOL (ORAL)* • PROPRANOLOL ER (ORAL)* • PROPRANOLOL / HCTZ (ORAL) • PROPRANOLOL SOLUTION (ORAL)* • PROPRANOLOL TABLET (ORAL)* • SOTALOL (ORAL)* GRANDPARENTING - YES 10

P&T Public Class Vote: BPH Treatments Reaching across Arizona to provide comprehensive quality health care for those in need 11

BPH Treatments PDL Recommendations (preferred products): • ALFUZOSIN (ORAL) • DOXAZOSIN (ORAL)* • DUTASTERIDE (ORAL) • FINASTERIDE (ORAL)* • TAMSULOSIN (ORAL)* • TERAZOSIN (ORAL)* Reaching across Arizona to provide comprehensive quality health care for those in need 12

P&T Public Class Vote: Calcium Channel Blockers Reaching across Arizona to provide comprehensive quality health care for those in need 13

Calcium Channel Blockers PDL Recommendations (preferred products): • NIFEDIPINE IR (ORAL)* • AMLODIPINE (ORAL)* • VERAPAMIL CAPSULE ER (ORAL)* • DILTIAZEM CAPSULE ER (ORAL)* • NIFEDIPINE ER (ORAL)* • DILTIAZEM TABLET (ORAL)* • VERAPAMIL TABLET ER (ORAL)* • FELODIPINE ER (ORAL)* • VERAPAMIL ER PM (ORAL)* • KATERZIA (ORAL) • VERAPAMIL TABLET (ORAL)* Reaching across Arizona to provide comprehensive quality health care for those in need 14

P&T Public Class Vote: Leukotriene Modifiers Reaching across Arizona to provide comprehensive quality health care for those in need 15

Leukotriene Modifiers PDL Recommendations (preferred products): • MONTELUKAST TABLET (ORAL) • MONTELUKAST CHEWABLE TABLET (ORAL) • MONTELUKAST GRANULES (ORAL) No PA required for children less than 4 years old Reaching across Arizona to provide comprehensive quality health care for those in need 16

P&T Public Class Vote: Phosphate Binders Reaching across Arizona to provide comprehensive quality health care for those in need 17

Phosphate Binders PDL Recommendations (preferred products): • CALCIUM ACETATE CAPSULE (ORAL) • CALCIUM ACETATE TABLET (ORAL) • RENAGEL (ORAL) • RENVELA TABLET (ORAL) • SEVELAMER CARBONATE TABLET (AG) (ORAL) • SEVELAMER CARBONATE TABLET (ORAL) GRANDPARENTING - NO Reaching across Arizona to provide comprehensive quality health care for those in need 18

P&T Public Class Vote: Sedative Hypnotics Reaching across Arizona to provide comprehensive quality health care for those in need 19

Sedative Hypnotics PDL Recommendations (preferred products): • ESZOPICLONE (ORAL) • RAMELTEON (ORAL) • ROZEREM (ORAL) • TEMAZEPAM (ORAL) – 15 mg and 30 mg capsules • ZOLPIDEM (ORAL) GRANDPARENTING – NO Reaching across Arizona to provide comprehensive quality health care for those in need 20

P&T Public Class Vote: Steroids, Topical Reaching across Arizona to provide comprehensive quality health care for those in need 21

Steroids, Topical PDL Recommendations (preferred products): • Low Potency Topical Steroid Agents o o o o o DERMA-SMOOTHE-FS (TOPICAL) FLUOCINOLONE 0. 01% OIL (TOPICAL)* HYDROCORTISONE ACETATE CREAM OTC (TOPICAL)* HYDROCORTISONE ACETATE OINTMENT OTC (TOPICAL)* HYDROCORTISONE-ALOE CREAM OTC (TOPICAL) HYDROCORTISONE CREAM OTC (TOPICAL)* HYDROCORTISONE CREAM (TOPICAL)* HYDROCORTISONE LOTION OTC (TOPICAL)* HYDROCORTISONE OINTMENT (TOPICAL)* 22

Steroids, Topical PDL Recommendations (preferred products): • Medium Potency Topical Steroid Agents o o o FLUTICASONE PROPIONATE CREAM (TOPICAL)* FLUTICASONE PROPIONATE OINTMENT (TOPICAL)* MOMETASONE FUROATE CREAM (TOPICAL)* MOMETASONE FUROATE OINTMENT (TOPICAL)* MOMETASONE FUROATE SOLUTION (TOPICAL)* Reaching across Arizona to provide comprehensive quality health care for those in need 23

Steroids, Topical PDL Recommendations (preferred products): • High Potency Topical Steroid Agents o o o BETAMETHASONE DIPROPIONATE LOTION (TOPICAL) BETAMET DIPROP / PROP GLY CREAM (TOPICAL)* BETAMETHASONE VALERATE LOTION (TOPICAL)* BETAMETHASONE VALERATE OINTMENT (TOPICAL)* FLUOCINONIDE CREAM (TOPICAL)* FLUOCINONIDE OINTMENT (TOPICAL)* FLUOCINONIDE SOLUTION (TOPICAL)* TRIAMCINOLONE ACETONIDE CREAM (TOPICAL)* TRIAMCINOLONE ACETONIDE LOTION (TOPICAL)* TRIAMCINOLONE ACETONIDE OINTMENT (TOPICAL)* Reaching across Arizona to provide comprehensive quality health care for those in need 24

Steroids, Topical PDL Recommendations (preferred products): • Very High Potency Topical Steroid Agents o o o o CLOBETASOL EMOLLIENT (TOPICAL) CLOBETASOL PROPIONATE CREAM (TOPICAL)* CLOBETASOL PROPIONATE GEL (TOPICAL)* CLOBETASOL PROPIONATE OINTMENT (TOPICAL)* CLOBETASOL PROPIONATE SOLUTION (TOPICAL)* HALOBETASOL PROPIONATE CREAM (TOPICAL) HALOBETASOL PROPIONATE OINTMENT (TOPICAL) Reaching across Arizona to provide comprehensive quality health care for those in need 25

New Drug Recommendations – Non-preferred • Mayzent • Cutaquig • Rocklatan • Egaten • Mavenclad • Sunosi • Evenity • Rinvoq • Diacomit • Vyndamax • Skyrizi Reaching across Arizona to provide comprehensive quality health care for those in need 26